Marble Dinosaur Egg*: Assessing Medication Adherence

*My version of a “clinical pearl.”

FIRST IN AN OCCASIONAL SERIES

“Clinical Pearl” is the name given to those little hints that may not be taught in medical school or postgraduate training, but have been discovered or devised over the years by us old coots who may still know a thing or two.

Via KevinMD comes this article about patients who lie, both about their medications and other things, occasionally to their severe detriment. Not knowing exactly what meds (and how much) a patient is actually taking can lead to fatal outcomes of prescription interactions.

Various ways of assessing medication adherence (a work I prefer to compliance, which sounds to me like bending patients) have been suggested, including specifically worded questions like, ““A number of my patients don’t take their medication as prescribed and they do it for a variety of reasons. What do you think might be going on with you?” Personally, I find that awkward and stilted; so here is what I have come up with.

First I ascertain medication name, dosages and frequencies. For folks who answer, “Whatever you’ve got down there, Doc” I smile and say, “This is sort of a quiz to make sure you know what you’re taking.” Most people are fine with that. Many have taken to carrying a small card or slip of paper with their meds, which I use to review and double-check with my chart. Once a year or so I’ll ask them to bring in all their med bottles, and we’ll go through them together. (The old “brown bag” review. One time I had fun teasing a long-time patient about her inability to follow directions; how could we do a “brown bag” review of her meds if she brought them in a plastic grocery bag?)

Finally, my magic “adherence” question:

(in a conspiratorial tone, face scrunched a little, with a tiny nod) How often do you forget to take them?

The implication is that everyone forgets now and then, I’m not going to be angry, and I really need to know. It works like a charm:

“Sometimes on the weekends, but I’m usually pretty good.”

“Honestly, I only get that second dose in once a week or so.”

“I’ll be honest with you, Doc; maybe 3 or 4 times a week.”

“Never! I take them every morning right after I brush my teeth.”

and stuff like that.

Remember: the secret to getting patients to tell you the truth about meds — or anything else, for that matter — is to make sure they don’t feel judged. And the only way to accomplish that is to refrain from being judgemental. (Although once more, the Tenth Law of the Dinosaur rears its impressive head: “Simple” and “Easy” are not necessarily the same.)

One thing strikes me though – I would find a “brown bag review” extremely insulting. Maybe for the elderly, I guess… but I would never go along with that myself, and would be quite offended if asked. Moreso if ordered. Doesn’t anyone object?

I’m sure that’s not how you mean it, but to say you have to look at and count pills for me implies that either I’m a liar, or too stupid to count. Again, from reading your posts, I’m sure that’s not what you mean. But if a doctor suggested that to me, that would be how I would feel.

By: Tracy2 on December 23, 2010 at 11:22 am

Another way to stop having your patients lie to you is to stop lying to them. For example, let’s say I’m a psychiatrist about to prescribe an atypical anti-psychotic: I say to patient, “In some people it can cause a little weight gain but not necessarily, if you’re careful about diet and exercise — and a small number of people may experience occasional sexual ‘side-effects’, but I think you’ll find the benefits far outweigh the side effects.” An honest MD would say, “Look, you’re going to probably gain 100 lbs and you won’t be able to have an orgasm, and there is a fair chance that you will develop uncontrollable tics and spasms, but trust me, you’re going to feel *a lot* better. Would the psychiatrist take what s/he prescribes the patient?

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